Sem 4 - Case 4
Bowel Trouble John, 65, was tired of his vegetarian daughter nagging him to eat fewer steak pies down at the pub and to eat more fruit and veg. Nevertheless, in the past few months he had been feeling that things weren’t quite right and went to his GP complaining of feelings of tiredness, unexplained weight loss and intermittent presence of blood in his faeces. This was accompanied by alteration of bowel habits with alternating constipation and increased frequency of defecation. Although the stools were loose, there was no watery diarrhoea. The complaint had been present for 3 months. Rectal digital examination failed to reveal anything and there was no abdominal mass on palpation. John, however, did have microcytic anaemia together with a low serum iron level John was referred to the district gastroenterology department where he underwent colonoscopy; this showed the presence of a large diffuse polypoid ulcerating mass in the upper half of the sigmoid colon. In addition, three polyps were identified. Excision biopsy of the polyps and a biopsy of the ulcerated mass was performed. Histopathological examination of the polyps showed tubular adenomas with mild to moderate epithelial dysplasia; the ulcerated mass showed a moderately differentiated adenocarcinoma. CT scans did not show any metastases, the chest radiograph was normal and serum proteins, calcium, bilirubin, alkaline phosphatase and creatinine were all within normal limits. John underwent sub-total colectomy together with removal of regional lymph nodes. Histopathological examination of this tissue revealed adenocarcinoma extending through the external muscle wall of the colon and presence of the tumour in the regional lymph nodes (TNM Stage III). John was advised to have adjuvant chemotherapy and agreed. He was given a combination of fluorouracil (5-FU) and folinic acid. John suffered with vomiting, stomatitis and diarrhoea during the chemotherapy but subsequently recovered and was kept under regular review. John had always been an active man who prided himself on his community spirit; as a result he was highly regarded by his friends and neighbours. John was normally fatalistic in his outlook on life and death. During the course of this illness he suffered progressively with bouts of depression and hopelessness, which John thought placed a great strain on him and his family's ability to cope, and may have affected the course of the disease. He was offered psychological therapy to help him examine his thoughts and manage his psychological distress. Eighteen months post-operation John was found to have a palpable abdominal mass. CT scans revealed hepatomegaly and multiple liver metastases. He was informed of the poor prognosis and chose not to have any further therapy. However, he continued to receive palliative care. After a short period at home, he was cared for in a hospice during the next 3 months, where his family regularly visited him. At the end of this time, he died due to complications arising from widespread meta. ILOs *To demonstrate a basic knowledge of the genetic basis of cancer including: sporadic and inherited cancers, predisposition to cancers, chromosomal abnormalities, somatic mutations, onvogenes, tumour suppressor genes, repication error repair genes, and DNA repair genes. *To demonstrate basic knowledge of the clinical investigation of the GI tract *To demonstrate basic knowledge of the laboratory tests used in this case and how they are carried out. *To demonstrate basic knowledge of the concepts of chemotherapy *To demonstrate basic knowledge of analysing faeces *To demonstrate knowlege of carcinoma in situ and malignant tumour *To demonstrate knowlege of the basic concepts of cell proliferation, differentiation, and death *To demonstrate knowlege of the structure and function of the large intestine and associated structures including lymph nodes and portal vein *To demonstrate knowlege of the therapeutic agents used in the case scenario *To demonstrate know understanding of the philosophy of palliative care. University Resources Please note that these may require you to log in to blackboard to access them. You can visit the full resource page for the case here, otherwise here are some of the main ones. Case resources *Ogden Health Psychology **pp381-385 and 387-390 for psychology and cancer **pp385-387 for interventions in cancer *Effects of psychosocial interventions on quality of life in adult cancer patients - A meta-analysis paper *End of life care resources **Dying Matters resources - DM website **Gold Standards framework - GS website **Treatment and care towards the end of life (PDF) - GMC advice **Let's talk about dying - TED talk by Peter Saul *Cancer treatment - Powerpoint by Greg Wilson Lectures *Overview of bowel cancer - Robert Metcalf *Anatomy & homeostasis of the GI tract (incl, immunology) - Joanne Pennock *Palliative care & significant illness - Iain Lawrie